HomeMy Public PortalAbout5954 ALESSANDRO AVE_Sewer__ C E808 10 63 /
76A642D APPLICATION FOR PE MIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCAL TY
NEAREST
FOR APPLICANT TO FILL IN GROSS ST
LEGAL
DESCRIPTION LOT NO OWNER ( J
�^ MAIL
BLOCK TRACT ClJ ,17
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT ` CITY '97( TEL NO
71:J9 .31
USE OF AA DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS W`
BK PG
CONTRACTOR } �
ADDRESS N CONNECTION bATA
CITY t TEL roo
NO STATION DEPTH
1��{ STATE UPPER
REGISTRATION NO ® LJ COUNTY MANHOLE REFERENCE
NO DESCRIPTION OF WOIRK FEE TYPE OF CON LE TH FROM
HOUSE SEWER CONNECTING TO Y URB P L M L TO P L r
PUBLIC SEWER @ SS 00 �7
IL
SEPTIC TANK SEEPAGE PIT OR P C NO O
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO /� V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO / ix
PRIVATE DISPOSAL SYSTEM @ E3 00 / 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I E15[M[1T RECORD INSTR NO DAT
WORK TO HOUSE SEWER @ $300 rj
OVERFLOW SEEPAGE PIT DRAINFIELD l!J
EXTN CESSPOOL DRYWELL MANHOLE @ Es 00 d
ALTER REPAIR OR ABANDON HOUSE STA ORTE ENCROACHMENT
ROACHMENT WIDENING N
SEWER OR DISPOSAL SYSTEM @ 53 00 STA
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERMIT S 200
AUTHORIZATION TOTAL FEE 7CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR f NEW HOUSE SEWER
OWNERS NT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ T APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY T I AM PROPER STERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUI BY LOS LE COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAfef AM THE GA NER ANDI ND TO DISCONNECT PLUG AND
RESIDE IN I E A DESCRIB D R SI ENT[ OPE ABANDON HOUSE SEWER
SIGNATURE ❑
M BACKFILL SEPTIC TANKS
OF PER
SEEP PIT fS) ❑ CESSPOOL
ALIDATIOI ', ROBERT A WOOD
(/ SUPERVISING MECHANICAL ENGINEER
K M O CASH
7 5 4 6tr\ N0V 2 4 1 0 D 7.0 0�